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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE ' <br /> Appl ication is hereby made to carry On business in the jurisdictional area of the San Joaquin Local Health District <br /> NBusiness Name (DBA) J �' -�v?sic Address ? <br /> z Owner _ ' F Address <br /> C <br /> J Firm Partners, Addresses and Telephone Nu bers <br /> aBusiness Telephone No. 67::a 3 . 7 Emergency Telephone No. ^�A <br /> Contractor Licence No. "? r— <br /> L Applicants Name (Print) f Titlee.^,ZnKQ-� Date <br /> Please check Applicable Category (1-7)and Fill in the Require, nformation 4 , <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL, License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD - <br /> Fpr July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name - ..R.S,or-R.C.E. No. <br /> Test Location Test Dat e/Tirhe <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location _ i _ <br /> Owner caf r* /j/ Address - <br /> ❑ SEPTIC TANK ❑ CESSPOOL © LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served;'- <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sit to uin County <br /> ordinances, state laws, and rules and re la ' s of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X / <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 13ANNUALLY [IPER UNIT E] PER SITE 11EACH ❑ January 1e rved By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITT CE $ AMOUNT DUE CHECKED <br /> DATE D T REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> or 09 <br /> Received by Date Receipt No. Permit No. Issua ce D e Mai ed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 <br />